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Effects of Ball Cauterization Following Loop Excision and Follow-Up Colposcopy

From the Department of Gynecology, Ioannina University Hospital, Ioannina, Greece.

Address reprint requests to: Evangelos Paraskevaidis, MD Department of Gynecology Ioannina University Hospital 45001 Ioannina Greece E-mail: koliops{at}ath.forthnet.gr

	Abstract

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Objective: To investigate whether central diathermy ball cauterization after loop excision affects satisfactory colposcopy at follow-up.

Methods: One hundred one consecutive women with the squamocolumnar junction visible at the ectocervix scheduled for loop excision were assigned alternately into two groups. In group A, diathermy ball cauterization was applied to the entire crater following excision. In group B, cauterization was avoided in a 2–3-mm zone around the new os. The women were re-examined 4 months postoperatively by colposcopy and microcolpohysteroscopy with specific intention to identify the location of the squamocolumnar junction. The examiners performing colposcopy and microcolpohysteroscopy were not aware of each other’s interpretation, or of the method of cauterization used.

Results: Follow-up colposcopy was satisfactory in 12 women in group A (24%) and 47 women in group B (92.2%) (P < .001). Forty-three women (86%) in group A and ten in group B (19.6%) had the squamocolumnar junction partly or fully located within the cervical canal (P < .001). Microcolpohysteroscopy located the squamocolumnar junction at a mean depth of 4.5 ± 2.4 mm (± standard deviation [SD]) in the women in group A and 1 ± 0.9 mm in group B (P < .001). Microcolpohysteroscopy could not be performed in 13 women in group A (26%) and one woman in group B (2%) (P < .001).

Conclusion: Diathermy ball cauterization at the new cervical os after loop excision results in a shift of the squamocolumnar junction toward the endocervical canal, and predisposes to cervical stenosis, thereby decreasing satisfactory colposcopy rates.

The large loop excision of the transformation zone (LLETZ) is one of the most widely used methods of treating cervical intraepithelial neoplasia (CIN). Coagulation of the cervical wound is indicated after the excision, because sometimes bleeding points occur. Hemostasis can be achieved by various means, but diathermy ball and rollerball coagulation are the preferred methods.^1,2 These two coagulation techniques are frequently used after loop excisional treatment either to control intraoperative bleeding and promote hemostasis at the immediate postoperative period, or to reduce the risk of residual disease by destroying possible islands of dysplastic epithelium at the edge of the cervical crater. However, no guidelines have been published regarding the extent to which the cervical crater should be coagulated.

In a previous prospective study of the management of early invasive cervical cancer using only large loop excision, we found that 93% of the women had satisfactory colposcopy at the follow-up visit,³ whereas satisfactory colposcopy rates after loop as low as 70% have been reported.⁴ This high rate of satisfactory colposcopy might have resulted from the policy of peripheral cauterization with deliberate avoidance of central cauterization around the new cervical os that was used in that study.

The present study tested this hypothesis. It was a prospective study of the location of the new squamocolumnar junction at follow-up colposcopy in women who had peripheral only or generalized ball cauterization after loop excision for CIN.

	Materials and Methods

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One hundred one consecutive women with the squamocolumnar junction visible at the ectocervix preoperatively, who were scheduled to undergo LLETZ because of cytologic and colposcopic indications of squamous intraepithelial neoplasia (SIL), were assigned alternately to two groups. In group A, diathermy ball cauterization following excision was applied to the entire crater, including the new os. In group B, cauterization was avoided in a 2–3-mm zone around the new os. The management protocol was selective "see and treat." Women with cytologic indications of SIL would undergo colposcopy. If colposcopy was either suggestive of CIN or unsatisfactory, a loop excision would be performed in the same visit without punch biopsies. To define the squamocolumnar junction preoperatively as ectocervical, we required an agreement between two colposcopists. One would then perform the LLETZ. The LLETZ was performed under local anesthesia with a Valley-Lab, Force-2 Unit (Boulder, CO). The loop sizes were selected according to the extension of the lesion. When the lesion extended high into the endocervix, a deeper loop excision in a hat-top configuration was performed. The excised specimen was measured by a ruler before fixation, thereby assessing the depth of excision.

The women had their first follow-up colposcopic evaluation approximately 4 months later, having already had a Papanicolaou test 1 month earlier. Follow-up cytology was considered abnormal when it was suggestive of SIL. The follow-up evaluation included colposcopy with particular attention to the entire squamocolumnar junction; this procedure was performed by the second colposcopist, who was masked to the method of cauterization. To characterize colposcopy as satisfactory, an endocervical tenaculum was used in cases in which the squamocolumnar junction was partly or fully located in the canal, in order to visualize its upper limit. In every woman, regardless of colposcopic results, microcolpohysteroscopy was also attempted except for one case. The gynecologist performing microcolpohysteroscopy was not aware of the location of the new squamocolumnar junction before the procedure. The microcolpohysteroscopy was performed with the standard technique using blue ink.⁵ A Hamou hysteroscope (Karl Storz, Tuttlingen, Germany) with a 3.5-mm probe was used without anesthesia and the highest endocervical location of the squamocolumnar junction was recorded. This procedure has been shown to be generally well tolerated.⁶ The patients were given a questionnaire after the procedure and were asked to grade the discomfort experienced as mild or none (0–5 on scale), moderate (6–7 on scale), or severe (8–10 on scale). Women in whom microcolpohysteroscopy was not feasible because of the inability of the hysteroscope to pass through the ectocervical os were characterized as having possible cervical stenosis. Peri- and postoperative morbidity data were recorded. Morbidity was defined as severe perioperative bleeding requiring surgical intervention, or episode of secondary hemorrhage or infection within the first month.

Eight women, three assigned to group A and five to group B, did not present for follow-up and were excluded from the study. The study was completed when 50 women from group A and 51 women from group B presented for follow-up. Statistical analysis of the results was done with Student t test and ². This study had the approval of the surgical sector of the University of Ioannina Medical School. All women gave written informed consent for their participation in the study.

	Results

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No significant differences were found between the two groups in terms of parity, number of vaginal deliveries, age, cone depth, and peri- or postoperative morbidity (Table 1). The proportion of defaulters did not differ significantly between the two groups (P = .508).

	Discussion

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Colposcopy may be helpful in the follow-up of women who have undergone treatment for CIN, especially in cases of incomplete excision and high-grade lesions, because the procedure is known to reveal residual disease in the presence of negative cytology.⁷ Even in cases of clear margins some women are at substantially increased risk of reappearance of CIN,⁸ and colposcopy may have a role in the early diagnosis of treatment failure in such women. Satisfactory colposcopy during the follow-up period could enhance detection of residual disease; many centers include at least one colposcopic evaluation during the first postoperative year.

Rates of satisfactory colposcopy after LLETZ have been reported to range from 70 to 90%.^4,9 These studies suggest a possible relationship between the cone dimensions and subsequent unsatisfactory colposcopy or cervical stenosis. In these studies, however, diathermy ball cauterization was used in an undefined number of cases. A specific effect of diathermy ball cauterization on the transposition of the new squamocolumnar junction has not been investigated, to the best of our knowledge. (MEDLINE search using key words LLETZ, squamocolumnar junction, diathermy ball, electrocoagulation, satisfactory colposcopy, cervical stenosis from 1989 to 2000, and search of related articles).

Our study suggests that diathermy ball cauterization at the new os after loop excision results in a significant number of cases in transposition of the squamocolumnar junction within the endocervical canal, and predisposes to cervical stenosis. It could be argued that alternate assignment could result in possible interpretation biases, but it should be noted that the main outcome measure was the location of the squamocolumnar junction, which was ectocervical in all cases preoperatively. Additionally, possible confounding factors such as age and parity were not statistically different between the two groups (Table 1). With the ordered method of assignment used in this study one could speculate that the operators knew which group a woman would be assigned to before loop excision. This was not possible, however, because the lists of the colposcopy clinics were prepared by the appointments secretary of the University Hospital and not by the colposcopists. It is a reasonable assumption that a generalized cauterization including the new os might have a beneficial effect in destroying residual disease, mainly in endocervically involved margins. This result was not found in our study because the number of women with abnormal follow-up results of cytology and colposcopy was similar between the two groups, although the actual numbers were small. The fact that no difference in unsatisfactory follow-up cytology was found between the two groups can be attributed to the routine use of Ayre spatulas and brushes for obtaining cervical smears.

	Footnotes

 
PII S0029-7844(00)01194-7

Received July 17, 2000. Received in revised form October 16, 2000. Accepted November 2, 2000.

	References

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1. Prendiville W, Cullimore J, Norman S. Large loop excision of the transformation zone (LLETZ). A new method of management for women with cervical intraepithelial neoplasia. Br J Obstet Gynaecol 1989;96:1054–60.[Medline]

2. Prendiville W. Large loop excision of the transformation zone. Clin Obstet Gynecol 1995;38:622–39.[Medline]

3. Paraskevaidis E, Kitchener H, Kalantaridou S, Agnanti N, Lolis D. Large loop conization for early invasive cervical cancer. Int J Gynecol Cancer 1997;7:96–9.

4. Murdoch JB, Grimshaw RN, Monaghan JM. Loop diathermy excision of the abnormal cervical transformation zone. Int J Gynecol Cancer 1991;1:105–11.

5. Soutter WP, Fenton DW, Gudgein P, Sharp F. Quantitative microcolpohysteroscopic assessment of the extent of endocervical involvement by cervical intraepithelial neoplasia. Br J Obstet Gynaecol 1984;91:12–5.

6. Paschopoulos M, Paraskevaidis E, Stefanidis K, Kofinas G, Lolis D. Vaginoscopic approach to outpatient hysteroscopy. J Am Assoc Gynecol Laparosc 1997;4:465–7.[Medline]

7. Paraskevaidis E, Jandial L, Mann EMF, Fisher PM, Kitchener HC. Pattern of treatment failure following laser for cervical intraepithelial neoplasia: Implications for follow-up protocol. Obstet Gynecol 1991;78:80–3.[Abstract/Free Full Text]

8. Paraskevaidis E, Lolis E, Koliopoulos G, Alamanos Y, Fotiou S, Kitchener HC. Cervical intraepithelial neoplasia outcomes after large loop excision with clear margins. Obstet Gynecol 2000;95:828–31.[Abstract/Free Full Text]

9. Luesley DM, Cullimors J, Redman CWE, Lawton FG, Emers JM, Rollason TA, et al. Loop diathermy excision of the cervical transformation zone in patients with abnormal cervical smears. BMJ 1990;300:1690–3.

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